<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005899
Report Date: 02/29/2024
Date Signed: 02/29/2024 01:38:10 PM


Document Has Been Signed on 02/29/2024 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:IN R GREAT HANDS - MONTEVIDEOFACILITY NUMBER:
306005899
ADMINISTRATOR:IN, RIZAFACILITY TYPE:
740
ADDRESS:1261 MONTEVIDEO AVENUETELEPHONE:
(714) 646-9648
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 6DATE:
02/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Tristan RaquipoTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Case Management inspection in conjunction with investigation into complaint number 22-AS-20220831133413. LPA met with Tristan Raquipo and explained the purpose of the inspection.

During the course of the investigation, deficiencies were observed. Upon request of Resident 1’s (R1’s) file, facility was unable to provide any documentation pertaining to R1. During interviews, Staff 1 (S1) stated R1 was at the facility from 8/17/22-8/26/22 and R1’s responsible party had taken all documentation upon discharge on 8/26/22.

Per California Code of Regulations Title 22, 87506(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff; additionally per 87506(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.

Based on observations made during this inspection, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/29/2024 01:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: IN R GREAT HANDS - MONTEVIDEO
FACILITY NUMBER: 306005899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2024
Section Cited
CCR
87506(a)

1
2
3
4
5
6
7
The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Licensee and Administrator will submit a statement that they have read and will be in compliance with regulation to LPA via email by POC date.
8
9
10
11
12
13
14
During the course of complaint investigation, facility was unable to provide any documentation pertaining to R1, which poses an immediate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
04/01/2024
Section Cited
CCR87506(e)

1
2
3
4
5
6
7
Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Licensee and Administrator will submit a statement that they have read and will be in compliance with regulation to LPA via email by POC date.
8
9
10
11
12
13
14
During the course of complaint investigation, facility was unable to provide any documentation pertaining to R1, which poses a potential health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2